A Pain in the Neck

Neck pain is a common musculoskeletal problem condition in many parts of the world and is increasing both among the general population and within specific occupations (such as construction workers and office  workers). It affects between 26% and 71% of the population at some point in their lives.

Researchers from Spain (Muñoz-Muñoz et al)  evaluated  adults with active (painful) Myofascial trigger points (MTrPs) and those without pain. They found that the referred pain elicited by active MTrPs in the neck and shoulder muscles contributed to symptoms in mechanical neck pain. Patients exhibited higher disability and worse sleep quality than controls. Sleep quality was associated with pain intensity and disability. No association between active MTrPs and the intensity of pain, disability, or sleep quality was found. Similar findings were also given by the study of Gerber et al.from George Mason Univ.

Researchers from Spain (De-la-Llave-Rincon et al.) also found that those with mechanical chronic neck pain had more latent MTrPs in the masticatory muscles and reduced jaw opening compared to healthy controls. These findings may suggest the spread of sensitization from the cervical segment to the trigeminal brain stem sensory nuclear complex.

A 2010 study from the UK (Artz et al) showed that sensorimotor function of the neck and shoulder muscles is altered in patients with neck pain. They suggest that the proprioceptors, including muscle spindles, develop a reduced sensitivity to mechanical stimuli.

A Swedish study investigated neck muscle activity and postural control in patients with whiplash-associated disorder. They found that during balance tasks with closed eyes and one-legged stance, the relative mean activity of all 4 muscles (anterior scalene, sternocleidomastoid, neck extensors and upper trapezius muscles) was significantly increased in whiplash-associated disorder compared with healthy controls. Postural sway was also significantly increased. Conclusion: Increased neck muscle activity and increased postural sway during simple balance tasks indicate disturbed sensory feedback patterns in people with whiplash-associated disorder, which may have negative consequences when performing daily activities.

Studies from a large population identified

• A strong association between muscle pain in the neck/shoulder region and headache was observed in adolescents, pointing to the importance of muscular pain for headache in adolescents.
• Muscular pain appears to be of particular importance in chronic TTH and in migraine (Blaschek et al., 2012)
• Neck pain is highly prevalent in the general population and even more prevalent in individuals with primary headaches. Prevalence is highest in coexistent Migraine+TTH, followed by pure TTH and migraine. Myofascial tenderness is significantly increased in individuals with neck pain.
• A possible link between migraine and neck pain may be the cervico-trigeminal convergence of neck and meningeal sensory afferents or a disturbed descending inhibition in migraine (Blaschek et al., 2014).
• The association between self-reported neck and shoulder pain is most pronounced in migraine with a high attack frequency (Landgraf et al., 2015).
• Patients with TTH exhibited decreased muscle strength in the neck extensor muscles, inducing a reduced cervical extension/flexion ratio compared to healthy people (Madsen et al, 2016).

Diagnosis

A definitive diagnosis of chronic neck pain is usually not possible. A therapist can usually palpate the unusual tenderness, but some may claim this is ‘just in your head’.Antonio Stecco et al. from Padua University, Italy used ultrasonography to look a the deep fascia. They found significant differences between healthy subjects and patients with chronic neck pain in the thickness of the upper side of the sternocleidomastoid fascia and the lower and upper sides of the right scalene fascia. They then hypothesized that that the loose connective tissue inside the fascia may play a significant role in the pathogenesis of chronic neck pain.

Meanwhile, researchers from George Mason Univ used another type of ultrasound instrument called Vibration elastography to look at Myofascial trigger points (MTrPs) in the upper trapezius for patients with chronic neck pain. They found the differences in tissue texture, active MTrPs have more homogeneous texture and heterogeneous stiffness when compared with normal, unaffected muscle. They also indicated that in subjects with chronic neck pain and active MTrPs, the abnormalities are not confined to discrete isolated nodules but instead affect the surroundings of the muscle surrounding palpable MTrPs.

Evidence-Based

A study involving 64 patients with neck pain from US in 2009 randomly allocated half of the participants for therapeutic massage and the other half with a self-care book. At 10 weeks, more participants randomized to massage experienced clinically significant improvement on the Neck Disability Index and on the symptom bothersomeness scale . After 26 weeks, massage group members tended to be more likely to report improved function, but not symptom bothersomeness. Differences between groups were strongest at 4 weeks and not evident by 26 weeks. No serious adverse experiences were reported.

A study in Poland involved 60 patients aged 37-82 years having neck pain. The patients were divided into two groups: one (30 persons) received kinesiotherapy and physiotherapy, and the other group (30 persons) additionally received therapeutic massage. The Neck Disability Index (NDI) and a Visual Analogue Scale (VAS) showed a significant pain reduction and improved performance and function after rehabilitation in both groups. Patients who had received massage demonstrated a statistically significant improvement in the range of flexion lateral bend to the right, and lateral bend to the left.

A study from Germany evaluated five sessions of cupping massage on chronic non-specific neck pain on  50 patients (half received cupping and the other is standard medical care). They found cupping improved pain and increased subjective well-being. The increase in pain pressure threshold is consistent with a reduced peripheral sensitization of deeper tissues and supports previous findings on dry cupping in chronic neck pain.

The Cochrane Database Systematic Review in 2012 looked at current studies on the effect of massage treatment on “mechanical neck disorder”. They found that (as usual) “No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain. As a stand-alone treatment, massage for mechanical neck disorder was found to provide an immediate or short-term effectiveness or both in pain and tenderness. Additionally, future research is needed in order to assess the long-term effects of treatment and treatments provided on more than one occasion.”

Later, a group of researchers called the Ottawa Panel  conducted another review on the use of massage compared to a control or other treatments for adults (>18 years) suffering from sub-acute and chronic neck pain. They found a total of 45 recommendations from ten articles were developed including 8 positive recommendations  and 23 neutral recommendations. They found that therapeutic massage can decrease pain, tenderness, and improve range of motion for sub-acute and chronic neck pain. They further concluded that massage interventions are effective for relieving immediate post-treatment neck pain symptoms, but data is insufficient for long-term effects.

And when you think it is enough, another review came up in 2013 from a Chinese group, looked at data twelve high-quality studies. In immediate effects, the meta-analyses showed significant effects of massage therapy for neck pain and shoulder pain versus inactive therapies. However, massage therapy did not show better effects for neck or shoulder pain when compared to active therapies.

Cost-Effectiveness

A 2012 review look at 5 studies that showed the cost-effectiveness of conservative treatments for neck pain.  One study found that manual therapy was dominant over physiotherapy and general practitioner care, whilst behavioural graded activity was not cost-effective compared to manual therapy. The combination of advice and exercise with manual therapy was not cost-effective compared to advice and exercise only. One study found that acupuncture was cost-effective compared to a delayed acupuncture intervention, and another study found no differences on cost-effectiveness between a brief physiotherapy intervention compared to usual physiotherapy. However the authors concluded that at present, the limited number of studies and the heterogeneity between studies warrant no definite conclusions on the cost-effectiveness of conservative treatments for non-specific neck pain.